INFORMATION ABOUT CHILDREN’S MERCY HOSPITALS AND CLINICS The purpose of this brochure is to provide you with a brief orientation to Children’s Mercy Hospitals and Clinics. It provides important information you need to know while at the hospital. Please read it carefully and ask about anything that you do not understand. Children’s Mercy Hospital commits to providing quality pediatric health care with service excellence and efficiency to everyone we serve. Service Excellence: Extraordinary Every Time At Children’s Mercy, Service Excellence is an essential component in the delivery of high-quality health care to children and their families, and in sustaining a great workplace for our passionate and dedicated colleagues. Everyone who represents Children’s Mercy is expected to demonstrate behaviors which create experiences that are “Extraordinary Every Time” for our patients, families, co-workers, referring providers, patrons, and payors. Those behaviors include the following Service Excellence standards: • • • • • • • • Acknowledge others’ presence right away, even when busy. Communicate making eye contact and at eye level when appropriate. Introduce yourself in person and on the phone; speak with a smile. Listen completely before responding. Help make things more convenient for patients, families and each other. Take responsibility to resolve problems. Make sure there are no remaining questions prior to leaving patients and families. Close each encounter on a positive note, including a word of thanks. Together with our patients, families and communities, we are creating a special place of care, service and respect. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 1 Fire In case of a fire: R – Rescue anyone in danger A – Alarm/Alert C – Contain/Confine E – Extinguish/Evacuate There are pull fire alarms throughout the hospital properties. Locate the fire alarm and fire extinguisher nearest to where you are working. When you use it: Remember P – pull the pin A –aim at the base of the fire S – squeeze the lever S – sweep from side to side Emergencies Safety Officer: 816-983-6946 Security: 816-234-3340 Children’s Mercy Hospital 913-696-8140 Children’s Mercy South Engineering: 816-234-3350 Children’s Mercy Hospital 913-696-8165 Children’s Mercy South Security Hotline: 112 Children’s Mercy Hospital 212 Children’s Mercy South Code Red (fire) or Code Blue (someone not breathing or has had a heart attack), dial: 111 Children’s Mercy Hospital 211 Children’s Mercy South 911 Hospital Hill (and/or Truman Security at 9-404-1916) 911 Children’s Mercy Northland 911 Children’s Mercy West 9-911 Teen Clinic 9-911 Crown Center 9-911 5520 College Blvd. Disaster If a disaster occurs outside or inside the hospital, you will hear: “Attention all personnel.” This will be followed by a specific Disaster Code designation. This will be repeated three times over the public address system. Wait for instructions from hospital personnel in charge. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 2 Tobacco Free Children’s Mercy Hospitals and Clinics is tobacco free. Tobacco products are not allowed in any area of the hospital, in any building the hospital owns or leases, or in any hospital vehicle. Sidewalks around Children’s Mercy Hospital are smoke free. Infection Control Hand washing is the MOST important means of infection control and should be done OFTEN. Wash hands for 10 - 15 seconds with running water, soap, and friction. Use a paper towel to turn off the faucet. Standard Precautions are used to make sure you do not have contact with someone else’s blood, body fluids, secretions, or excretions. Protective barriers (gowns, gloves, masks, eyewear) are available in all patient care areas. Ask if you need help finding them. Any precaution signs on patient doors should be followed. Infectious Waste There are two types of trash in the hospital. General hospital waste consists of paper products, pop cans, bottles, and all non-patient care items. It goes in regular trash cans. Infectious waste consists of patient care items soiled with blood or body fluids, sharps and sharps containers. This will be discarded in RED bags. If you have any questions about this, ask the Children’s Mercy employee in charge. For more details, please refer to the Infectious Waste Handling and Disposal Policy. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 3 Back Safety Use your body right! Bend with your knees, not your back. Lift with your legs, holding objects close to your body. Plan ahead and get help when needed. Walk and sit with good posture. Keep head up and sit straight. Sit in chairs low enough to keep your knees equal to or slightly lower than your hips and keep your back against the chair. Doing these simple things will help keep you from hurting yourself! Patients in Custody The hospital requires that all forensic patients (those in custody of legal services for criminal charges) be guarded at all times by the law enforcement agency responsible for them. All external officers, when coming into the facility, will be familiar with the life safety, security, and infection control policies. The Children’s Mercy Security department will assist law enforcement or correctional officers as appropriate when requested. Children’s Mercy security officers may provide relief coverage for external officers for meals or other personal breaks. If a patient is in restraints, please refer any questions to their nurse. Please follow the Restraint / Seclusion Policy and the Restraint Procedure. A copy may be obtained from the Children’s Mercy employee in charge. Quiet Please remember you are in the hospital, and loud noise is disturbing to patients and families. Anti-Harassment The hospital strives to offer a workplace free from any type of harassment. Harassment is defined as unwelcome or unsolicited verbal, non-verbal, printed, electronic mail, or physical conduct which substantially interferes with an employee’s job performance or which creates an intimidating, hostile, or offensive work environment. If you believe you have been the subject of harassment, report the incident immediately to your supervisor. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 4 Privacy Is Important CMH&C is committed to protecting the privacy and confidentiality rights of our patients and families. In order to provide care to our patients and their families, we collect, use, maintain, and disclose as appropriate information about the patient's medical condition, medical and social history, medications, and family illnesses. CMH&C policies require that all members of our workforce and affiliates such as you maintain privacy and confidentiality of patient information. This includes all patient information collected by the organization. Our patients and their families have a right to assume that all information regarding care received at CMH&C will be held in confidence. This means that it can be disclosed only when authorized by the patient/parent or by law. During your affiliation, you may hear and see things of a private nature. You have a duty to protect the patients’ rights of privacy and confidentiality. Patient information never should be discussed in public areas. Having received patient information, you may not further distribute that information. This includes both individual health information and aggregate data. On April 14, 2003, CMH&C implemented the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule passed by Congress in 1996 into its daily operations. HIPAA adds new rights and requirements to the long tradition of confidentiality in health care, and it has heightened patient awareness of existing rights. Since the implementation of HIPAA, other privacy regulations have been enacted such as HITECH (Health Information Technology for Economic and Clinical Health) and State privacy laws. The Hospital must also comply with these regulations. What Medical Information is Considered Confidential? HIPAA defines Protected Health Information (PHI) as individually identifiable health information that is created or received by a health care provider, health plan, employer, or health care clearinghouse and that relates to the past, present or future mental or physical health of the individual; provision of health care to the individual; or, payment for the provision of health care to the individual, which is transmitted or maintained in any form or medium. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 5 Individual identifiers include: • • • • • • • • • Name Social Security Number Medical Record Number Geographic Location Except State All Dates, Except Year Age >89 Phone Number Fax Number E-Mail Address • • • • • • • • • Biometric ID – Finger Voice Prints Health Plan Number Account Number License Number Vehicle Identification Device Numbers URL’s & IP Address Any Other Unique Number, Code PHI may be verbal, written or electronic and may be part of an individual record or included in aggregate data such as hospital census reports, acuity reports, and quality reports. It is all deserving of our protection. Notice of Privacy Practices One way in which CMH&C demonstrates our commitment to privacy and confidentiality is by providing each patient with a statement describing how their PHI is protected. The Notice of Privacy Practices is provided to patients the first time they register for services at CMH&C. The notice is also posted in each clinic and on the Hospital website. The Notice is long and detailed because the HIPAA regulations specify the subjects that must be included. Minimum Necessary Fundamental to HIPAA is the concept that only the minimum amount of information needed to complete a particular task should be collected, used or divulged. However, because all information may be needed to care for a patient, the minimum necessary principle does not apply to treatment. As an affiliate, you may be exposed to information of a highly personal nature that must be protected. You may hear PHI or you may see it in a chart. If you have questions about what may be discussed and with whom you may discuss it, please ask a Hospital staff member. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 6 Communication with Family, Friends, and Others As a general rule, health care providers do not discuss PHI with family members, friends and others unless the patient/parent authorizes the disclosure to the individual. During your affiliation, unless within the scope of you agreement with the Hospital, please refrain from engaging in conversation with the patient, his/her family, friends, or other personal representative. Penalties If conscientious efforts are made to comply with HIPAA regulations, there is less worry about sanctions or penalties. However, the law does provide for fines to be accessed to the covered entity (Hospital) and/or individual for a violation of the HIPAA rules in the amount of $100 per incident up to $25,000 per person, per year, per standard for violations. If violations are done “willingly and knowingly”, under false pretenses, or for personal gain, commercial advantage or malicious harm, the fines can rise to $250,000. These latter infractions are criminal offenses and carry penalties of imprisonment in addition to monetary fines. HITECH, another federal regulation that protects patient privacy allows the patient to file a civil action against the individual who breached the patient’s privacy. Affiliates Privacy Responsibilities • • • • • • Keep all information, including patient and family information acquired in the course of your affiliation confidential. Do not attempt to access or review patient records unless part of your duties at the Hospital. Refrain from seeking patient information that you do not need to fulfill your affiliation responsibilities. If you write notes regarding a patient for use during your affiliation, before leaving the hospital, dispose of them in the shredding consoles. Attempts should be made to not refer to the patient by name. (i.e. 5 year old ER patient, etc.) Do not identify patients/families to anyone during or after completing your affiliation. Do not disclose, copy, release, sell, loan, review, alter, transmit, destroy, or remove from the premises any patient records or patient information. Do not post on social media sites any references to our patients. Even if the patient is not identified by name they may still be identifiable. Do not take photographs of patients or staff without their written authorization. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 7 Reporting Privacy Concerns Report known or suspected privacy breaches to the Privacy Officer, Mikki Massey, at 816-701-4573 or call the Compliance Hotline at 816-460-1000. To Learn More About HIPAA If you would like additional information on HIPAA, a good place to begin is on the government web site: http://www.hhs.gov/ocr/hipaa. Your Role in Patient Information Security  Print-based medical records need to be kept in a secure area or in a safe location with access to authorized people only. These areas should be locked when not in use. Remember to return medical records to the Health Information Department at the end of your shift.  If you use a computer as part of your affiliation, a password (not to be shared) must be used to control access to PHI.  If your computer is available/viewable by non-authorized people, use a screensaver or reposition to protect the viewing of PHI.  Be sure to exit applications, log off or lock the desktop (by pressing <Ctrl><Alt><Del> keys) before you leave a computer.  Back up computer files by placing them in your home (U:) drive.  If data transfer is part of your duties, only use media which is encrypted.  Always encrypt emails which contain patient, financial or confidential information.  Lock cabinets that contain PHI when you leave your area.  When disposing of paper or media containing confidential information, place the items into a Shred-It box.  Become familiar with emergency procedures.  If someone is in your area that you do not recognize, ask them to identify themselves and inform your supervisor or the Security Department.  To report a computer security incident, contact the Help Desk at 816-234-3454 or extension 53454. Compliance The Hospital’s Corporate Compliance program helps the hospital and staff follow the law and do the right thing. Supported by the Code of Conduct, the hospital expects you to act honestly and ethically. If you observe improper conduct, report this to your supervisor or the Compliance Officer at 816-701-4570 or anonymously through the Compliance Hotline at 816-460-1000. Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 8 Attestation Statement (Visitor or Student Orientation Document) My signature indicates that I have received and reviewed the information included in this document and will comply with this information. If at any time I have questions or concerns I will contact _________________(Department Supervisor/Preceptor) or another employee of The Children’s Mercy Hospital. . Signature Date Children’s Mercy Hospitals and Clinics 2401 Gillham Road Kansas City, MO 64108 Information About Children’s Mercy Hospital / Privacy Is Important _ 2/2012 Page 9